Given the way psychotherapy has evolved over the past century, I am not one who places all my eggs in one basket regarding one theory about how to work as a therapist. I think the integration and eclectic movements that took hold in the 1980s & 1990s allowed therapists to move away from the idea that there is one right way of doing therapy, and that everyone must align with that proven way of working. Likewise the integrationist movement allowed therapists to free themselves from the notion that individually each therapist must choose one way of working among the many theories and approaches that have been developed over a century that began with Freud. As a therapist whose framework is existentialism, I integrate many approaches for my work with clients.
I offer the little preface above because over the next couple of months, I am going to discuss an approach that I find useful, and one that I will integrate within my framework for working with clients. It is Acceptance & Commitment Therapy, or simply ACT. The approach integrates well with several other conceptualizations, such as cognitive therapy, Motivational Interviewing, and existential work. I find its conceptualization squares and meshes well with existential thought along several avenues, including its take on experiential avoidance, values clarification, self-knowledge, and the conceptualized self. Though those avenues are more easily addressed as integrating well with existential thought, all the points of ACT on its Hexaflex I find mesh well with existential thought.
It is the ACT conceptualization as presented in its Hexaflex that forms the structure of my discussion. For this month’s article, I will focus on the Hexaflex as ACT therapists use it to discuss what they call the Six Core Pathological Processes. Though I do not necessarily like the nomenclature pathological, I find I do like much of the conceptualization that ACT presents through this model. ACT therapists designate these processes as Psychological Inflexibility. In next month’s article, I will discuss the ACT conceptualization that counters the pathological processes delineated by ACT therapists with their six core processes of Psychological Flexibility. From the ACT perspective, Psychological Flexibility is a holistic understanding of human functioning that involves living in the present moment, opening up to life’s possibilities and vicissitudes, and doing what matters. ACT theorists and therapists delineate Psychological Flexibility along six core processes they conceptualize in their Hexaflex. These six core processes are: 1) Contact with the Present Moment (Be Here Now); 2) Acceptance (Open Up); 3) Defusion (Watch Your Thinking); 4) Values (Know What Matters); 5) Committed Action (Do What It Takes); and 6) Self-As-Context (Pure Awareness). These six processes are explored in therapy to counter any points that emerge when clients become trapped in psychological inflexibility via the Six Core Pathological Processes. In this blog article I will delineate these pathological processes as conceptualized by ACT therapists. I will discuss the remedy or counter to these pathological processes in next month’s blog article.
ACT: The Six Core Pathological Processes
Just as the Hexaflex is used to delineate the core processes for Psychological Flexibility, likewise it is used to conceptualize the core processes of Psychological Inflexibility. The ACT Model conceptualizes Psychological Inflexibility in terms of the following six core processes: 1) Dominance of the Conceptualized Past and Future; Limited Self-Knowledge: 2) Experiential Avoidance; 3) Cognitive Fusion; 4) Lack of Values Clarity/Contact; 5) Unworkable Action; and 6) Attachment to the Conceptualized Self. From the perspective of ACT therapists, the two processes of cognitive fusion and experiential avoidance give rise to and maintain all the pathological processes. I may be playing with words here, but I really like the notion of inflexibility as opposed to pathology. From my perspective too much of therapy pathologizes experiences that people go through that can be understood in proper contexts. In other words, I don’t view experiences as depression and anxiety as medicalized illnesses that need to be cured. Indeed I understand that these experiences can impact human beings at a physiological level that may need to be addressed via medications. But depression and anxiety are experiences that come with life. I believe other phenomena such as schizophrenia, bipolarity, and forms of dissociation and emotional dysregulation will be eventually explained along neurological avenues. However, personal concerns that come with those experiences can be addressed by therapy utilizing ACT and other approaches. For example, how might an individual relate to the notion that for most of his life he will have to be medicated for some form of schizophrenia? How might she view herself for being labeled with such a diagnosis? These and others like them are personal concerns that can be worked through in therapy.
Cognitive fusion is the experience whereby a person becomes entangled in his thoughts to the point that they dominate his awareness and have a huge impact on his behavior. What is not being said here is that it is wrong to think. The focus of the work is more on the thoughts to which one is fused, and how that fusion impacts day-to-day action. For example, a depressed person might ruminate significantly on the thought I can’t change anything in my life. Or they might feel, It’s too much effort to try to change anything; nothing works. These thoughts are often connected to past memories that might have been extremely painful. Experiences such as failed relationships, business failures, or other disappointing ventures become the focus of fused beliefs. Clinical depression involves fusion to the point that individuals can experience excessive worry, continual rumination, and endlessly trying to understand why am I like this. Much of what ACT calls cognitive fusion meshes well with the cognitive therapy conceptualization of negative thinking about the self, others, and future. But as will be explained in this and next month’s blog articles, ACT takes a different approach from cognitive therapy in working with cognitive fusion.
It is natural for anyone to want to avoid unpleasant experiences, and that is true of private experiences as well as contextual ones. We find ourselves trying to find ways to quit thinking about things, to cease holding onto recurring painful memories, and seeking to avoid uncomfortable feelings. Fusion and avoidance are like two sides of a coin. They are hard to fissure, so they form the coin that drives the entire machine. The name of the therapy, Acceptance & Commitment Therapy, provides a clue to the therapeutic work that is used to counter experiential avoidance – acceptance, which utilizes a mindful approach to therapeutic work.
Dominance of the Conceptualized Past and Future/Limited Self Knowledge
Fusion and avoidance typically lead individuals to become stuck in certain contexts; consequently, they lose contact with the present, or living in the here-and-now. We probably all know people, and even can recall our own personal experiences, where we so tightly hang onto a past experience, or put off living due to an extreme focus on and concern about the future. Being stuck in either the past or the future robs us of here-and-now experiences. Though not unanimous by any stretch of the imagination, many depressed individuals tend to hang onto past failures while anxious clients fear the future on some level. Both the past and the future, while not unimportant, can rob us of living in the here-and-now.
Lack of Values Clarity/Contact
This process as described by ACT therapists meshes well with existential thought. Individuals can become immersed in situations, lost in certain contexts, and sense that their lives lack direction because they are not clear on what they truly value. Individuals can experience a disconnect between the way they are living on the one hand, and, on the other hand, the fulfillment in life they hope to find because they might be acting on values about which they are not clear or do not truly believe. Individuals can inculcate values from their social contexts without truly assessing whether or not they value what they claim to value. Values clarification can help these clients determine what they hold as important so as to act on what they truly believe.
If people lose contact with the here-and-now and are unclear as to what they truly believe, they find themselves in patterns of behavior that simply are not getting them what they want. In other words, what they are doing is not working. What they are doing is not working because what they are doing is not aligned with anything they really believe or value. Hence, rather than mindful actions based on personal values, people can become caught up in mindless activities, reactionary behaviors, and turn into automatons, all of which can lead to purposeless action, directionless living, and constant experiential avoidance because of the lack of fulfillment and pleasure in life. Aligning action with values can help individuals begin to move purposefully through life.
Attachment to the Conceptualized Self
We all can present, tell, or write some form of narrative that speaks to who and what we believed ourselves to be. These narratives form the way we describe ourselves. We can fuse with our self-narratives to the point that we are our self descriptions. I understand the problem of identifying with negative self-narratives, such as I’m a failure. But I depart in some sense from ACT on this point in that I do believe in a core self. While mindfulness can help us better understand ourselves as self-in-context, I’m not in alignment with the total Eastern view of the human being as not have a self, or viewing one’s understanding of the self as an illusion. I also agree that overly identifying with even positive self-narratives can be problematic if we continually deflect input from personal experiences and try to solidify a particular notion about ourselves as a total narrative about who we are. I find myself somewhat more Western here with the notion that an individual is a self-in-process, continually undergoing change, and hopefully growth, throughout his or her life. To be in process requires openness to life. I don’t believe it requires not having a core self as much Eastern thought tends to hold. Nonetheless, having stated my differences here, I think the work that ACT pursues with clients to help them defuse from problematic self-narratives is a valuable part of the work in this approach.
Obviously, these six core processes do not stand alone. They overlap and interact with one another, and one process can trigger another. If I believe that I’m a failure, then I will experientially avoid trying new and risky ventures. These six core processes of psychological inflexibility are countered by the flip side of the six core processes of psychological flexibility. These processes I’ll tackle in next month’s blog article. The notion of flexibility is one with which I resonate. After all, what is flexibility other than adaptation. We all move through our lives, evaluate our experiences, determine whether to hold or discard certain values, and seek to live in alignment with what we know and believe. We are in process and constantly engaging change and growth. We are in constant movement toward carving out an adaptive and flexible understanding of our identity or self.
References: Harris, R. (2009). ACT made simple. Oakland, CA: New Harbinger Publications.
John V. Jones, Jr, Ph.D., LPC-S/April 14th, 2017